Cognitive Behavioral Therapy for Insomnia Shows Promise in Treating Alcohol Use Disorder

Mary Beth Miller, PhD

Credit: MU Health Care

A new study suggested cognitive behavioral therapy (CBT) should be considered a first-line treatment for insomnia. The investigation explored the impact of improved insomnia symptoms as a mechanism for better alcohol use disorder (AUD) outcomes among veterans.¹

Evidence has supported CBT-I as an effective treatment, even when engaged in a digital format.² Despite the strong association between AUD and insomnia, the first-line treatment for insomnia, cognitive behavioral therapy for insomnia (CBT-I), is often delayed until abstinence from alcohol is achieved.¹

However, these results indicated addressing insomnia symptoms early in AUD treatment can potentially improve overall treatment outcomes and enhance the well-being of individuals with comorbid AUD and insomnia regardless of abstinence.

CBT vs Sleep Hygiene

The randomized clinical trial conducted by Mary Beth Miller, PhD, University of Missouri, and a team of investigators, aimed to evaluate the feasibility, acceptability, and preliminary efficacy of early CBT-I intervention for veterans undergoing treatment for AUD.

Between 2019 and 2022, participants were recruited from the Addictions Treatment Program at a Veterans Health Administration hospital. Eligible participants included 67 individuals receiving treatment for AUD who met criteria for insomnia disorder and reported alcohol use within the past two months at baseline. The study population was primarily made up of men (91%) with an average age of 46.3 years (SD, 11.8).

Participating patients were randomly assigned to either the CBT-I group (n = 32), which received 5 weekly sessions of CBT-I, or the control group (n = 35), which received a single session on sleep hygiene. Sleep diaries were completed for 7 days at each assessment, follow-up assessments were conducted posttreatment and at 6 weeks.

The main measures of interest in this study were posttreatment insomnia severity, assessed using the Insomnia Severity Index, as well as the frequency of any drinking and heavy drinking, defined as 4 drinks for women and ≥ 5 drinks for men, during the follow-up period. Alcohol-related problems were also evaluated using the Short Inventory of Problems.

Investigators also examined whether the reduction in insomnia severity following CBT-I treatment mediated the effects of CBT-I on alcohol use outcomes at the 6-week follow-up assessment.

Alcohol Abstinence Unnecessary for Intervention

Of those initially randomized, 59 (88%) provided posttreatment or follow-up data, with 31 in the CBT-I group and 28 in the sleep hygiene group. The results demonstrated that patients who received CBT-I experienced significantly greater reductions in insomnia severity compared with the sleep hygiene control group at both posttreatment and follow-up assessments.

Additionally, the CBT-I group showed improvements in sleep efficiency at posttreatment and follow-up. At the follow-up assessment, patients in the intervention group reported decreased alcohol-related problems, and this effect was mediated by the change in insomnia severity following treatment.

However, according to the data, no significant differences were observed between the 2 groups regarding abstinence or frequency of heavy drinking.

This randomized clinical trial provides evidence for the effectiveness of CBT-I as an early intervention for insomnia symptoms among individuals receiving treatment for AUD. The findings highlight that CBT-I outperformed sleep hygiene in reducing insomnia severity and alcohol-related problems over time.

Further research is warranted to confirm these findings and explore additional interventions that can address heavy drinking frequency in this population.

“This is a significant finding because it challenges current recommendations to postpone behavioral insomnia treatment until patients have achieved 4 weeks or longer of abstinence,” investigators wrote.

“Indeed, data from this study suggest that waiting for individuals to succeed with abstinence (which may not be necessary for all individuals with AUD) may be a missed opportunity to improve patients’ sleep and influence their experience of alcohol-related harm.”

References:

1. Miller MB, Carpenter RW, Freeman LK, et al. Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial. JAMA Psychiatry. Published online June 21, 2023. doi:10.1001/jamapsychiatry.2023.1971
2. Grossi G. Optimizing Insomnia Treatment: Combination Therapy vs. dCBT-I vs. Medication. HCPLive. Apr 17, 2023. https://www.hcplive.com/view/optimizing-insomnia-treatment-combination-therapy-cbt-medication